TABLE OF SPECIFICATIONS

UNDERGRADUATE TEACHING
PAEDIATRIC SURGERY
SHAIKH ZAYED FEDERAL POSTGRADUATE MEDICAL INSTITUTE

OUTCOMES

Acquire the knowledge of health promotion, disease prevention and management of

common diseases/problems in children (including diseases and problems of the
newborn).

Attitude/Affect/Values to be inculcated

Demonstrate polite and gentle patient handling.

Observes Aseptic Techniques.
Keeps confidentiality of the patient.
Uphold medical ethics.

A. History taking
1. To understand the content differences in obtaining a medical history on a pediatric
patient compared to an adult.

a. To understand how the age of the child has an impact on obtaining an

appropriate medical history.

2. To understand all the ramifications of the parent as historian in obtaining a medical

history in a paediatric patient.

3. To understand the appropriate wording of open-ended and directed questions, and

appropriate use of each type of question.

4. To develop an awareness of which clinical settings it is appropriate to obtain a

complete medical history compared to a more limited, focused history.

Competencies:

1. To obtain an accurate and complete history of a pediatric patient in different age

groups (<1 year; 1-5 years; > 5 years).

B. Principles of Surgery
Metabolic response to Surgical Trauma and homeostasis.
Pathophysiology and Management of Shock.
Fluid, electrolyte and acid base balance.
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 Haemorrhage, coagulapathy and Blood/products Transfusion and its
complications.
Nutrition of surgical patients.
Wounds, wound repair and its complications.

C. Basic life support (BLS)

B. Lump/Swellings (general)
Congenital
Traumatic
Inflammatory
Neoplastic

Neck Swellings

Lymphadenapathy (Inflammatory), acute and chronic

Chronic granulomatous
Neoplastic benign/malignant Lymphatic leukemia
Autoimmune disorders
Lipoma
Neurofibroma
Sebaceous cyst
Sublingual dermoid
Thyroglossal cyst
Salivary Glands: calculi, enlargement (benign/malignant)
Thyroid gland enlargement
Branchial cysts, sinus or fistula
Cystic hygroma
Carotid artery tumor

D. Pain Abdomen

Appendicitis
Non-specific abdominal pain
Mesenteric adenitis
Intussusception
Urinary tract infection
Hernia
Upper respiratory tract infection

E. Inguinoscrotal Swelling
Inguinal hernia
Femoral swellings
Encysted hydrocele of cord
Varicocele
Lymphangiactasis
Funiculitis
Diffuse lipoma of cord
Inflammatory thickening of cord
Malignant extension of testis (including testicular malignancy)
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 Undescended and/or Ectopic testis
Retractile testis
Torsion of testis
Enlarged lymph nodes
Abscess

F. Genitourinary
Undescended Testis
Circumcision
Hypospadias

G. Congenital & Developmental Disorders

Congenital Talipes equino varus (CTEV)
Congenital dislocation of hip (CDH)
Flat foot
Perth‟s Disease
Slipped Capital Femoral Epiphysis
Prevention of Contractures and Deformities.

H. Miscellaneous
Paediatric Tumours
Neonatal surgical problems
Tracheoesophageal malformations
Pyloric stenosis
Hirschprung‟s disease
Imperforate anus
Intestinal obstruction
Foreign body (Aspirated or Ingested)

I. Logbook

Pre-Operative assessment of the patient.

I/V Cannulation and Intra-operative fluid Management.
Induction of General Anaesthesia and Tracheal Intubation.
Demonstration of Spinal Block (O).
Demonstration of Epidural Block (O).
Demonstration of Local Blocks in Paediatric Surgery.
Demonstration of CPR.
Post-Operative Care/Pain Management.
Introduction to the ICU.
Demonstration of Anaesthesia Machine and other instruments
Demonstration of Sterilization procedures in O.T and ICU.
Demonstration of Vital Sign Monitoring

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 HISTORY TAKING
Differences of a Pediatric History Compared to an Adult History:

I. Content Differences

A. Prenatal and birth history

B. Developmental history

C. Social history of family - environmental risks

D. Immunization history

II. Parent as Historian

A. Parent’s interpretation of signs, symptoms

1. Children above the age of 4 may be able to provide some of their own history

2. Reliability of parents’ observations varies

3. Adjust wording of questions - “When did you first notice Johnny was
limping”? instead of “When did Johnny’s hip pain start”?

B. Observation of parent-child interactions

1. Distractions to parents may interfere with history taking

2. Quality of relationship

C. Parental behaviors/emotions are important

1. Parental guilt - nonjudgmental/reassurance

2. The irate parent: causes

Outline of the Pediatric History:

I. Chief Complaint

A. Brief statement of primary problem (including duration) that caused family to seek
medical attention

II. History of Present Illness

A. Initial statement identifying the historian, that person’s relationship to patient and
their reliability

B. Age, sex, race, and other important identifying information about patient

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 C. Concise chronological account of the illness, including any previous treatment with
full description ofsymptoms (pertinent positives) and pertinent negatives. It belongs
here if it is relates to the differential diagnosis for the chief complaint.

III. Past Medical History

A. Major medical illnesses

B. Major surgical illnesses-list operations and dates

C. Trauma-fractures, lacerations

D. Previous hospital admissions with dates and diagnoses

E. Current medications

F. Known allergies (not just drugs)

G. Immunization status - be specific, not just up to date

IV. Pregnancy and Birth History

A. Maternal health during pregnancy: bleeding, trauma, hypertension, fevers,

infectious illnesses, medications, drugs, alcohol, smoking, rupture of membranes

B. Gestational age at delivery

C. Labor and delivery - length of labor, fetal distress, type of delivery (vaginal,
cesarean section),use of forceps, anesthesia, breech delivery

D. Neonatal period - Apgar scores, breathing problems, use of oxygen, need for
intensive care, hyperbilirubinemia, birth injuries, feeding problems, length of stay,
birth weight

V. Developmental History

A. Ages at which milestones were achieved and current developmental abilities -

smiling, rolling, sitting alone, crawling, walking, running, 1st word, toilet training, riding
tricycle, etc (see developmental charts)

B. School-present grade, specific problems, interaction with peers

C. Behavior - enuresis, temper tantrums, thumb sucking, pica, nightmares etc.

VI. Feeding History

A. Breast or bottle fed, types of formula, frequency and amount, reasons for any

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 changes in formula

B. Solids - when introduced, problems created by specific types

C. Fluoride use

VII. Review of Systems: (usually very abbreviated for infants and younger children)

A. Weight - recent changes, weight at birth

B. Skin and Lymph - rashes, adenopathy, lumps, bruising and bleeding, pigmentation
changes

C. HEENT - headaches, concussions, unusual head shape, strabismus, conjunctivitis,

visual problems,hearing, ear infections, draining ears, cold and sore throats, tonsillitis,
mouth breathing, snoring, apnea, oralthrush, epistaxis, caries

D. Cardiac - cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest
pain, palpitations

E. Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough, sputum,

hemoptysis, TB

F. GI - stool color and character, diarrhea, constipation, vomiting, hematemesis,

jaundice, abdominal pain, colic, appetite

G. GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary

stream, polyuria, previous infections, facial edema

H. Musculoskeletal - joint pains or swelling, fevers, scoliosis, myalgia or weakness,

injuries, gait changes

I. Pubertal - secondary sexual characteristics, menses and menstrual problems,

pregnancies, sexual activity

J. Allergy - urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions

VIII. Family History

A. Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer, abnormal

bleeding, allergy and asthma, epilepsy

B. Mental retardation, congenital anomalies, chromosomal problems, growth

problems, consanguinity, ethnic background

IX. Social

A. Living situation and conditions - daycare, safety issues

B. Composition of family

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 C. Occupation of parents

PHYSICAL EXAMINATION
Objectives

To understand how the general approach to the physical examination of the child will be
different compared to thatof an adult patient, and will vary according to the age of the
patient.
To observe and demonstrate physical findings unique to the pediatric population, and to
understand how these findings may change depending upon the age of the child.

Competencies

To obtain accurate vital signs (Temperature, HR, RR, BP) in a pediatric patient in different
age groups and to be ableto evaluate these vital signs compared to age-adjusted
normals. To understand the normal variation in temperature depending on the route of
measurement.
To complete a thorough physical examination on a pediatric patients in different age
groups. Two of these should be supervised by the attending staff in Clinic 6.

Differences in Performing A Pediatric Physical Examination Compared to an Adult:

I. General Approach

A. Gather as much data as possible by observation first

B. Position of child: parent’s lap vs. exam table

C. Stay at the child’s level as much as possible. Do not tower!!

C. Order of exam: least distressing to most distressing

D. Rapport with child

1. Include child - explain to the child’s level

2. Distraction is a valuable tool

E. Examine painful area last-get general impression of overall attitude

F. Be honest. If something is going to hurt, tell them that in a calm fashion. Don’t lie
or you lose credibility!

G. Understand developmental stages’ impact on child’s response. For example,

stranger anxiety is a normal stage of development, which tends to make examining
a previously cooperative child more difficult.

II. Vital signs

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 A. Normals differ from adults, and vary according to age

1. See “code card” for charts of age-adjusted normals

B. Temperature

1. Tympanic vs. oral vs. axillary vs. rectal

C. Heart rate

1. Auscultate or palpate apical pulse or palpate femoral pulse in infant

2. Palpate antecubital or radial pulse in older child

D. Respiratory rate -Observe for a minute. Infants normally have periodic breathing so
that observing foronly 15 seconds will result in a skewed number.

E. Blood pressure

1. Appropriate size cuff - 2/3 width of upper arm

2. Site

F. Growth parameters - must plot on appropriate growth curve

1. Weight

2. Height/length

3. OFC: Across frontal-occipital prominence so greatest diameter

(Occipital Frontal Circumference)

III. Unique findings in pediatric patients (See outline below)

Outline of a Pediatric Physical Examination

I. Vitals - see above

II. General

A. Statement about striking and/or important features. Nutritional status, level of

consciousness, toxic or distressed, cyanosis, cooperation, hydration, dysmorphology,
mental state

B. Obtain accurate weight, height and OFC

III. Skin and Lymphatics

A. Birthmarks - nevi, hemangiomas, mongolian spots etc

B. Rashes, petechiae, desquamation, pigmentation, jaundice, texture, turgor

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 C. Lymph node enlargement, location, mobility, consistency

D. Scars or injuries, especially in patterns suggestive of abuse

IV. Head

A. Size and shape

B. Fontanelle(s)

1. Size

2. Tension - calm and in the sitting up position

C. Sutures - overriding

D. Scalp and hair

V. Eyes

A. General

1. Strabismus

2. Slant of palpebral fissures

3. Hypertelorism or telecanthus

B. EOM

C. Pupils

D. Conjunctiva, sclera, cornea

E. Plugging of nasolacrimal ducts

F. Red reflex

G. Visual fields - gross exam

VI. Ears

A. Position of ears

1. Observe from front and draw line from inner canthi to occiput

B. Tympanic membranes

C. Hearing - Gross assessment only usually

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 V. Nose

A. Nasal septum

B. Mucosa (color, polyps)

C. Sinus tenderness

D. Discharge

VI. Mouth and Throat

A. Lips (colors, fissures)

B. Buccal mucosa (color, vesicles, moist or dry)

C. Tongue (color, papillae, position, tremors)

D. Teeth and gums (number, condition)

E. Palate (intact, arch)

F. Tonsils (size, color, exudates)

G. Posterior pharyngeal wall (color, lymph hyperplasia, bulging)

H. Gag reflex

V. Neck

A. Thyroid

B. Trachea position

C. Masses (cysts, nodes)

D. Presence or absence of nuchal rigidity

VI. Lungs/Thorax

A. Inspection

1. Pattern of breathing

a. Abdominal breathing is normal in infants

b. Period breathing is normal in infants (pause < 15 seconds)

2. Respiratory rate

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3. Use of accessory muscles: retraction location, degree/flaring

4. Chest wall configuration

B. Auscultation

1. Equality of breath sounds

2. Rales, wheezes, rhochi

3. Upper airway noise

C. Percussion and palpation often not possible and rarely helpful

VII. Cardiovascular

A. Auscultation

1. Rhythm

2. Murmurs

3. Quality of heart sounds

B. Pulses

1. Quality in upper and lower extremities

VIII. Abdomen

A. Inspection

1. Shape

a. Infants usually have protuberant abdomens

b. Becomes more scaphoid as child matures

2. Umbilicus (infection, hernias)

3. Muscular integrity (diasthasis recti)

B. Auscultation

C. Palpation

1. Tenderness - avoid tender area until end of exam

2. Liver, spleen, kidneys

a. May be palpable in normal newborn

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3. Rebound, guarding

a. Have child blow up belly to touch your hand

IX. Musculoskeletal

A. Back

1. Sacral dimple

2. Kyphosis, lordosis or scoliosis

B. Joints (motion, stability, swelling, tenderness)

C. Muscles

D. Extremities

1. Deformity

2. Symmetry

3. Edema

4. Clubbing

E. Gait

1. In-toeing, out-toeing

2. Bow legs, knock knee

a. “Physiologic” bowing is frequently seen under 2 years of age and will spontaneously
resolve

3. Limp

F. Hips

1. Ortolani’s and Barlow’s signs

X. Neurologic - most accomplished through observation alone

A. Cranial nerves

B. Sensation

C. Cerebellum

D. Muscle tone and strength

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 E. Reflexes

1. DTR

2. Superficial (abdominal and cremasteric)

3. Neonatal primitive

XI. GU

A. External genitalia

B. Hernias and Hydrocoeles

1. Almost all hernias are indirect

2. Can gently palpate; do not poke finger into the inguinal canal

C. Cryptorchidism

1. Distinguish from hyper-retractile testis

2. Most will spontaneously descend by several months of life

D. Tanner staging in adolescents - See Tanner Staging handouts

E. Rectal and pelvic exam not done routinely - special indications may exist

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